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202108-140309

2021

Healthfirst Inc.

Medicaid

Blood Disorder

Inpatient Hospital

Medical necessity

Upheld

Case Summary

Diagnosis: Symptomatic Anemia.

Treatment: Inpatient Admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient has a past medical history of seizure, acute cystitis, acute liver failure (related to Lamictal use), gastritis, migraine, heavy menses, and recent COVID (coronavirus) 19 pneumonia and pulmonary embolism. She presented to the emergency department (ED) from urgent care for evaluation of headache and vaginal bleeding for 1 week. The patient was on Xarelto, and she was on day 7 of her menses. She was admitted for management of requiring blood transfusion. Her hemoglobin was 6.8. She received 2 units of packed red blood cells (PRBC) and an infusion of iron and was discharged home.

This patient was symptomatic. In addition, she fulfills the transfusion guidelines for use of blood components: her hemoglobin was less than 8 so, transfusion was necessary.
Could transfusion be done as an outpatient? It is obvious that in this day and age, transfusions are done routinely in outpatient settings (oncology clinics, infusion centers, even at home). So, the need for transfusion is not a reason for admission.

The transfusion could have been completed in the ED without the need for admission. Following transfusion, the patient could have been monitored for a few hours in the ED, her complete blood count (CBC) repeated and then discharged home with a follow up within 24 hours with her primary physician or gynecologist.

Nothing was done in the hospital that could not be done as an outpatient.

Milliman care guidelines list the clinical indication for inpatient care for patients with anemia. These include active massive hemorrhage, active hemolysis, cognitive impairment, tachycardia, orthostatic changes, heart failure, chest pain, syncope.

The patient was stable and did not have any of the above indications for admission.
Based on all of the above, admission was not medically necessary.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.

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